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Patients less than 70 years of age, of reasonable health, can skip the face-to-face specialist consultation for fast tracked access to colonoscopy and gastroscopy.

For further convenience patients will receive a phone call telehealth consultation from the treating specialist Avoiding the need to book a consultation.

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Direct Access Endoscopy Online Referral Form

    * mandatory fields

    PATIENT DETAILS

    Patient's Given Name *

    Patient's Last Name *

    Patient's Middle Names

    Patient's Date of Birth (dd/mm/yyyy)*

    Patient's Telephone (Mobile)*

    Patient's Email Address *

    Patient's Residential Address *

    Does patient have Medicare?*

    Patient's Medicare Number

    Medicare Reference Number (the number in front of your name)

    Does patient have private health insurance?*

    Patient's Private Health Insurer

    Patient's Private Health Insurance Membership Number

    Is the patient taking blood thinners?

    Is the patient taking diabetic medications?

    Does the patient have a coronary stent or valve replacement?

    REFERRING DOCTOR’S DETAILS

    Referring Doctor's first and last name

    Referring Doctor's phone number or practice details

    Referring Doctor's fax number, email or HealthLink EDI

    Referring Doctor's Provider Number

    PROCEDURE DETAILS

    What is the reason for having an endoscopy procedure?*

    Procedure required*

    Please add any additional comments

    Does the patient give permission for one of our staff to call them and organise their booking? *

    * Yes, patient consents to being contacted.